1 Rothman Institute, Thomas Jefferson University Hospital, Department of Orthopaedic Surgery, Philadelphia, PA, USA

2 Thomas Jefferson University Hospital, Department of Orthopaedic Surgery, Philadelphia, PA, USA


Background: This study aimed to analyze national and institutional trends in shoulder arthroplasty utilization based
on patient race.
Methods: The Nationwide Inpatient Sample (NIS) was employed to determine racial trends in shoulder arthroplasty
utilization at a national level. An institutional database was then utilized to retrospectively identify all patients, undergoing
shoulder arthroplasty within 2011-2013. Descriptive statistics were used to compare self-identified black and non-black
Results: The NIS identified 256,832 primary shoulder arthroplasties within 2005-2011. Black patients constituted
3.92% (n=10,074) of cases. Utilization increased from 3.36% in 2005 to 4.49% in 2011. Locally, a total number of
1,174 primary shoulder arthroplasties were performed, the recipients of 5.96% (n=70) of which were black. Females
accounted for 48/70 (68.6%) of black patients. Black patients had a higher body mass index (33.6 vs. 30.1, P<0.0001)
and were younger (62.6 vs. 67.2 years, P<0.0001), compared to the non-black patients. Regarding insurance type,
1,074 patients (i.e., 65 black and 1,009 non-black) had comprehensive insurance data. Chi-square analysis of five
major insurance categories, including private, Medicare, Medicaid, workers’ compensation, and personal injury,
indicated no difference in insurance patterns (χ2=3.658, P=0.454).
Conclusion: The findings revealed significant racial disparity in shoulder arthroplasty utilization both at national and
institutional levels. This disparity exists despite the similar rates of osteoarthritis in both white and black patients. Black
patients in our institution had similar clinical, demographic, and socioeconomic characteristics as in our non-black
patients. The obtained results highlighted the need for the expansion of black patients’ access to care services related
to major joint reconstruction.
Level of evidence: III


Main Subjects

1. Allen KD, Helmick CG, Schwartz TA, DeVellis RF, Renner
JB, Jordan JM. Racial differences in self-reported pain
and function among individuals with radiographic
hip and knee osteoarthritis: the Johnston County
Osteoarthritis Project. Osteoarthritis Cartilage. 2009;
2. Centers for Disease Control and Prevention (CDC).
Racial disparities in total knee replacement among
Medicare enrollees--United States, 2000-2006.
MMWR Morb Mortal Wkly Rep. 2009; 58(6):133-8.
3. Dunlop DD, Manheim LM, Song J, Sohn MW, Feinglass
JM, Chang HJ, et al. Age and racial/ethnic disparities
in arthritis-related hip and knee surgeries. Med Care.
2008; 46(2):200-8.
4. Dunlop DD, Song J, Manheim LM, Chang RW. Racial
disparities in joint replacement use among older
adults. Med Care. 2003; 41(2):288-98.
5. Hoaglund FT, Oishi CS, Gialamas GG. Extreme
variations in racial rates of total hip arthroplasty for 

primary coxarthrosis: a population-based study in
San Francisco. Ann Rheum Dis. 1995; 54(2):107-10.

6. Ibrahim SA, Stone RA, Han X, Cohen P, Fine MJ,
Henderson WG, et al. Racial/ethnic differences in
surgical outcomes in veterans following knee or hip
arthroplasty. Arthritis Rheum. 2005; 52(10):3143-51.
7. Lavernia CJ, Alcerro JC, Rossi MD. Fear in arthroplasty
surgery: the role of race. Clin Orthop Relat Res. 2010;
8. Liu JH, Zingmond DS, McGory ML, SooHoo NF, Ettner
SL, Brook RH, et al. Disparities in the utilization of
high-volume hospitals for complex surgery. JAMA.
2006; 296(16):1973-80.
9. Singh JA. Epidemiology of knee and hip arthroplasty:
a systematic review. Open Orthop J. 2011; 5(1):80-5.
10. Skinner J, Zhou W, Weinstein J. The influence
of income and race on total knee arthroplasty
in the United States. J Bone Jt Surg Am. 2006;

11. Skinner J, Weinstein JN, Sporer SM, Wennberg JE.
Racial, ethnic, and geographic disparities in rates of
knee arthroplasty among medicare patients. N Engl J
Med. 2003; 349(14):1350-9.
12. Wilson MG, May DS, Kelly JJ. Racial differences in
the use of total knee arthroplasty for osteoarthritis
among older Americans. Ethn Dis. 1994; 4(1):57-67.
13. Jain NB, Higgins LD, Guller U, Pietrobon R, Katz
JN. Trends in the epidemiology of total shoulder
arthroplasty in the United States from 1990-2000.
Arthritis Rheum. 2006; 55(4):591-7.
14. Schwartz BE, Savin DD, Youderian AR, Mossad D,
Goldberg BA. National trends and perioperative
outcomes in primary and revision total shoulder
arthroplasty: trends in total shoulder arthroplasty. Int
Orthop. 2015; 39(2):271-6.
15. Vegini JB, Steglich V, Bonilauri Ferreira AP, Gandhi
M, Shah J, Pietrobon R. Do insurance and race
represent independent predictors of undergoing
total shoulder arthroplasty? A secondary data
analysis of 3529 patients. J Shoulder Elbow Surg.
2012; 21(5):661-6.
16. Dillon CF, Rasch EK, Gu Q, Hirsch R. Prevalence of
knee osteoarthritis in the United States: arthritis
data from the Third National Health and Nutrition
Examination Survey 1991-94. J Rheumatol. 2006;
17. Jordan JM, Helmick CG, Renner JB, Luta G, Dragomir
AD, Woodard J, et al. Prevalence of knee symptoms and
radiographic and symptomatic knee osteoarthritis
in African Americans and Caucasians: the Johnston
County Osteoarthritis Project. J Rheumatol. 2007;
18. Jordan JM, Helmick CG, Renner JB, Luta G, Dragomir
AD, Woodard J, et al. Prevalence of hip symptoms and
radiographic and symptomatic hip osteoarthritis in
African Americans and Caucasians: The Johnston
county osteoarthritis project. J Rheumatol. 2009;
19. Tepper S, Hochberg MC. Factors associated with hip
osteoarthritis: data from the First National Health
and Nutrition Examination Survey (NHANES-I). Am J
Epidemiol. 1993; 137(10):1081-8.
20. Braga L, Renner JB, Schwartz TA, Woodard J, Helmick
CG, Hochberg MC, et al. Differences in radiographic
features of knee osteoarthritis in African-Americans
and Caucasians: the Johnston county osteoarthritis
project. Osteoarthritis Cartilage. 2009; 17(12):1554-61.
21. Nelson AE, Braga L, Braga-Baiak A, Atashili J,
Schwartz TA, Renner JB, et al. Static knee alignment
measurements among Caucasians and African
Americans: The Johnston county osteoarthritis
project. J Rheumatol. 2009; 36(9):1987-90.
22. Healthcare Cost and Utilization Project (HCUP).
Introduction to the HCUP National Inpatient Sample
(NIS) 2012. Rockville, MD: Agency for Healthcare
Research and Quality; 2014.
23. Houchens RL, Elixhauser A. Using the HCUP
Nationwide Inpatient Sample to estimate trends
(updated for 1988–2004). Rockville, MD: US Agency
for Healthcare Research and Quality; 2006.

24. Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future
young patient demand for primary and revision joint
replacement: national projections from 2010 to 2030.
Clin Orthop Relat Res. 2009; 467(10):2606-12.
25. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A
new method of classifying prognostic comorbidity in
longitudinal studies: development and validation. J
Chronic Dis. 1987; 40(5):373-83.
26. Deyo RA, Cherkin DC, Ciol MA. Adapting a
clinical comorbidity index for use with ICD-9-CM
administrative databases. J Clin Epidemiol. 1992;
27. Wennberg JE, Fisher ES, Goodman DC, Skinner
JS. The dartmouth institute for health policy and
clinical practice. Available at: URL: http://www.; 2016.
28. State and county quick facts. Census Bureau US.
Available at: URL:
states/00000.html; 2013.
29. Delaware valley analytical data report:
demographics of transit zones. Delaware Valley
Regional Planning Commission. Available at: URL:
Uploads/2008DelawareValleyADR17.pdf; 2015.
30. Health coverage by race and ethnicity: the potential
impact of the affordable care act. Medicaid and
The Uninsured. Available at: URL:
care-act/; 2013.
31. Aughinbaugh A, Robles O, Sun H. Marriage and
divorce: patterns by gender, race, and educational
attainment. Monthly Lab Rev. 2013; 136(1):1.
32. Smith A. African Americans and technology use: a
demographic portrait. Washington, DC: Pew Research
Center; 2014.
33. Allen KD, Golightly YM, Callahan LF, Helmick CG,
Ibrahim SA, Kwoh CK, et al. Race and sex differences
in willingness to undergo total joint replacement: the
Johnston county osteoarthritis project. Arthritis Care
Res. 2014; 66(8):1193-202.
34. Blum MA, Singh JA, Lee GC, Richardson D, Chen W,
Ibrahim SA. Patient race and surgical outcomes after
total knee arthroplasty: an analysis of a large regional
database. Arthritis Care Res. 2013; 65(3):414-20.
35. Groeneveld PW, Kwoh CK, Mor MK, Appelt CJ, Geng M,
Gutierrez JC, et al. Racial differences in expectations
of joint replacement surgery outcomes. Arthritis
Rheum. 2008; 59(5):730-7.
36. Hausmann LR, Hanusa BH, Kresevic DM, Zickmund S,
Ling BS, Gordon HS, et al. Orthopedic communication
about osteoarthritis treatment: does patient race
matter? Arthritis Care Res. 2011; 63(5):635-42.
37. Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Variation
in perceptions of treatment and self-care practices in
elderly with osteoarthritis: a comparison between
African American and white patients. Arthritis
Rheum. 2001; 45(4):340-5.
38. Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK.
Differences in expectations of outcome mediate African
American/white patient differences in “willingness”

to consider joint replacement. Arthritis Rheum. 2002;

39. Mota RE, Tarricone R, Ciani O, Bridges JF, Drummond
M. Determinants of demand for total hip and knee
arthroplasty: a systematic literature review. BMC
Health Serv Res. 2012; 12(1):225.
40. Shavers VL, Bakos A, Sheppard VB. Race, ethnicity,
and pain among the U.S. adult population. J Health
Care Poor Underserved. 2010; 21(1):177-220.